Library: Policy
317:2-3-1. Definitions
Revised 7-1-23
The following words or terms used in the Subchapter shall have the following meaning, unless the context clearly indicates otherwise:
"Adverse benefit determination" means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service or payment for the service is therefore denied, reduced or terminated and in accordance with Title 36 of Oklahoma Statute (O.S.) § 6475.3.
"Appeal" means a review of an adverse benefit determination performed by a CE or DBM or according to managed care law, regulations, and contracts.
"C.F.R." means the Code of Federal Regulations.
"Contracted entity" or "CE" means an organization or entity that enters into or will enter into a capitated contract with the Oklahoma Health Care Authority (OHCA) for the delivery of services that will assume financial risk, operational accountability, and state-wide or regional functionality in this act in managing comprehensive health outcomes of Medicaid members. This includes an accountable care organization, a provider-led entity, a commercial plan, a dental benefit manager, or any other entity as determined by the OHCA.
"Dental benefits manager" or "DBM" means an entity that meets the definition of a Prepaid Ambulatory Health Plan (PAHP) as per 42 C.F.R. § 438.2 and is under contract with the OHCA to manage and deliver all services described in this SoonerSelect Dental Contract and who handles claims payment and prior authorizations and coordinates dental care with participating providers and Enrollees. Also referred to as a "Contractor".
"Exigent circumstances" means a situation in which a reasonable person applying the appropriate standard would consider a member's health condition to be urgent with identifiable harm that could reasonably be expected to occur if the requested health care service is not provided promptly. The appropriate standard requires the assessment of a member's health condition through application, at minimum, of established, accepted standards of medical practice. Evidence of the member's condition may be demonstrated by indications from the treating provider or from the member's medical record, including but not limited to such information as the member's diagnosis, symptoms, or test results.
"Grievance" means a member's expression of dissatisfaction about any matter other than an adverse benefit determination and may include, but is not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a contracted entity employee or contracted provider, or failure to respect the Enrollee's rights regardless of whether remedial action is requested. A grievance includes a Enrollee's right to dispute an extension of time to make an authorization decision when proposed by the Contractor.
"Health plan" means any person or entity that is licensed as a health maintenance organization (HMO) by the State of Oklahoma to provide or arrange for the delivery of basic health care services to Enrollees on a prepaid basis, except for copayments or deductibles for which Enrollee is responsible, or both, that meets the definition of an HMO as delineated in the Oklahoma State Medicaid Plan and that contracts with the state to provide services to Enrollees. "Health plan" is synonymous with "health carrier".
"Member" means an individual eligible for Medicaid in the State of Oklahoma, eligible for a managed care program, and enrolled in a CE or DBM. "Member" is synonymous with "Enrollee".
"OAC" means the Oklahoma Administrative Code.
"OHCA" means the Oklahoma Health Care Authority.
"O.S." means the Oklahoma Statutes.
"Prepaid ambulatory health plan" or "PAHP" means the same in these rules as defined at 42 C.F.R. § 438.2.
"Prepaid inpatient health plan" or "PIHP" means the same in these rules as defined at 42 C.F.R. § 438.2.
"Primary care case management" or "PCCM" means the same in these rules as defined at 42 C.F.R. § 438.2.
"Primary care case management entity" or "PCCM entity" means the same in these rules as defined at 42 C.F.R. § 438.2.
"Prior authorization" or "PA" means a requirement that a member, through a provider, obtain the CE or DBM approval before a requested medical service is provided or before services by a non-participating provider are received. Prior authorization is not a guarantee of claims payment; however, failure to obtain prior authorization may result in denial of the claim or reduction in payment of the claim. For purposes of these rules, "prior authorization" is included as a determination of health care services within the term "adverse benefit determination".
"Provider" means a health care or dental provider licensed or certified in this state.
